The Natural History of Splenic Artery Aneurysms: Factors That Predict Aneurysm Growth.

PURPOSE: To examine the natural history of splenic artery aneurysms (SAAs) at a single institution and assess the effect of patient factors and aneurysm characteristics on aneurysm growth. MATERIALS AND METHODS: This single-center retrospective study included patients with SAAs who underwent serial imaging over 30 years (1990-2020). Data regarding patient demographics and aneurysm characteristics were collected. The variables contributing to aneurysm growth were assessed using nonparametric tests for continuous variables and chi-square test for categorical variables. Multivariable linear regression was performed using aneurysm growth rate as a continuous dependent variable. RESULTS: A total of 132 patients were included in this study. The median maximum diameter of the SAAs was 15.8 mm (range, 4.0-50.0 mm). Growth over time was observed in 39% of the aneurysms, whereas the remaining 61% were stable in size. Of aneurysms that increased in size, the median aneurysm growth rate was 0.60 mm/y (range, 0.03-5.00 mm/y). Maximum aneurysm diameter of >2 cm and the presence of >50% mural thrombus were significant positive predictors for aneurysm growth (P = .020 and P = .022, respectively). Greater than 50% rim calcification was a significant negative predictor for aneurysm growth (P = .009) in multivariate analysis. CONCLUSIONS: A larger baseline SAA size, presence of mural thrombus, and lack of rim calcification are associated with increased aneurysm growth rate.

Disparities in access to endovenous treatment options in chronic lower extremity superficial venous insufficiency: A national 7-year analysis.

OBJECTIVE: The goal of this study was to analyze trends in treatment access for chronic superficial venous disease and to identify disparities in care. METHODS: This retrospective study was exempt from institutional review board approval. The American College of Surgeon National Surgical Quality Improvement Program database was used to identify patients who underwent vein stripping (VS) and endovenous procedures for treatment of chronic superficial venous disease. Endovenous options included radiofrequency ablation (RFA) and laser ablation. Data was available from 2011 to 2018 and demographic information was extracted for each patient identified by Current Procedural Terminology codes. For all racial and ethnic groups, trend lines were plotted, and the relative rate of change was determined within each specified demographic. RESULTS: There were 21,025 patients included in the analysis. The overall mean age was 54.2 years, and the majority of patients were female (64.8%). In total, 27.9%, 55.2%, and 16.9% patients underwent VS, RFA, and laser ablation, respectively. Patients who received laser ablation were older (P < .001). Hispanic ethnicity was associated with significantly lower odds of receiving endovascular thermal ablation (EVTA) over VS (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.64-0.78; P < .001). American Indian/Alaska Native patients were more likely to receive EVTA over VS (OR, 4.02; 95% CI, 2.48-6.86); similarly, Native Hawaiian/Pacific Islander patients were more likely to receive EVTA over VS, although this difference was not statistically significant (OR, 1.44; 95% CI, 0.93-2.27). On multinomial regression, Hispanic patients were less likely to receive RFA over VS, whereas American Indian/Alaskan Native patients were more likely to receive RFA over VS. In all racial and ethnic groups, the percentage of endovenous procedures increased, whereas vein stripping decreased. CONCLUSIONS: Based on a hospital-based dataset, demographic indicators, including age, sex, race, and ethnicity, are associated with differences in endovenous treatments for chronic superficial venous insufficiency suggesting disparities in obtaining minimally invasive treatment options among certain patient groups.

Use of Polyurethane-Covered Stents for Exclusion of Pulmonary Arteriovenous Malformations.

PURPOSE: To evaluate the safety, technical success and short-term effectiveness of polyurethane-covered stent (PK Papyrus, BioTronik, Berlin) in the treatment of pulmonary arteriovenous malformations (PAVMs) that are not amenable to embolotherapy. MATERIALS AND METHODS: In this IRB-approved, retrospective study, data from patients who received polyurethane-covered stents for exclusion of PAVMs were analyzed. The study included 5 patients (all women) with a median age of 40 years (range 25-60). Patients presented with hypoxemia, TIAs, and/or epistaxis; 4 were confirmed to have HHT. All had multiple PAVMs diagnosed on chest CT and underwent embolization with other devices in addition to the polyurethane-covered stent. The indication for stent placement in all cases was a short and/or tortuous feeding artery. Safety was assessed by immediate or short-term complications, e.g., migration, stent thrombosis, and fracture. Technical success was defined as the ability to accurately place the stent at the intended location. Effectiveness was defined as successful exclusion of PAVM with no perfusion across the AVM. RESULTS: Technical success of stent placement was 100%. AVM exclusion rate was 80% after single stent deployment; in the case of incomplete exclusion, success was achieved using an overlapping stent to completely cover a second feeding artery. During the median follow-up period of 5 months (range 2-10), all stents remained patent, and AVMs were excluded without other complications. CONCLUSION: Exclusion of PAVMs with polyurethane-covered stents is technically feasible, safe, and shows short-term effectiveness for PAVMs with a short/tortuous feeding artery when traditional embolization techniques are not possible.

Circulating and non-circulating proteins and nucleic acids as biomarkers and therapeutic molecules in ovarian cancer.

Ovarian cancer is the second most fatal gynecological cancer. For the last decade or so significant use of non-circulating and circulating biomarkers has been highlighted. However, the study of such biomarkers at nanovesicle technology such as exosomes, proteomic and genomics studies could further contribute to better identification of anomalous protein and networks which could act as potential targets for biomarker and immunotherapy development. This review provides an overview of the circulating and non-circulating biomarkers with the aim of addressing the current challenges and potential biomarkers that could lead to early ovarian cancer diagnosis and better management. By means of this review we also lay a hypothesis that characterization of exosomal protein, nucleic acid content from body fluids (serum, plasma, urine, etc.) can decode the secret of disease and potentially improve diagnostic sensitivity which could further lead to more effective screening and early detection of the disease.

The Role of Artificial Intelligence in the Detection and Implementation of Biomarkers for Hepatocellular Carcinoma: Outlook and Opportunities.

Liver cancer is a leading cause of cancer-related death worldwide, and its early detection and treatment are crucial for improving morbidity and mortality. Biomarkers have the potential to facilitate the early diagnosis and management of liver cancer, but identifying and implementing effective biomarkers remains a major challenge. In recent years, artificial intelligence has emerged as a promising tool in the cancer sphere, and recent literature suggests that it is very promising in facilitating biomarker use in liver cancer. This review provides an overview of the status of AI-based biomarker research in liver cancer, with a focus on the detection and implementation of biomarkers for risk prediction, diagnosis, staging, prognostication, prediction of treatment response, and recurrence of liver cancers.

Diagnosis and Management of Persistent Pulmonary Arterio-venous Malformations following Embolotherapy.

Embolotherapy is the primary treatment for pulmonary arterio-venous malformations (PAVMs). Approximately, 2-25% of PAVMs demonstrate persistence following embolization. Early identification and treatment of persistent PAVMs are critical to mitigating life threatening complications. The presence of prior embolic devices and complex angioarchitecture of persistent PAVMs pose technical challenges during repeat embolotherapy. In this article, we review patterns of persistence, factors affecting the persistence, endovascular treatment techniques, and outcomes.

Role of Machine Learning in Precision Oncology: Applications in Gastrointestinal Cancers.

Gastrointestinal (GI) cancers, consisting of a wide spectrum of pathologies, have become a prominent health issue globally. Despite medical imaging playing a crucial role in the clinical workflow of cancers, standard evaluation of different imaging modalities may provide limited information. Accurate tumor detection, characterization, and monitoring remain a challenge. Progress in quantitative imaging analysis techniques resulted in "radiomics", a promising methodical tool that helps to personalize diagnosis and treatment optimization. Radiomics, a sub-field of computer vision analysis, is a bourgeoning area of interest, especially in this era of precision medicine. In the field of oncology, radiomics has been described as a tool to aid in the diagnosis, classification, and categorization of malignancies and to predict outcomes using various endpoints. In addition, machine learning is a technique for analyzing and predicting by learning from sample data, finding patterns in it, and applying it to new data. Machine learning has been increasingly applied in this field, where it is being studied in image diagnosis. This review assesses the current landscape of radiomics and methodological processes in GI cancers (including gastric, colorectal, liver, pancreatic, neuroendocrine, GI stromal, and rectal cancers). We explain in a stepwise fashion the process from data acquisition and curation to segmentation and feature extraction. Furthermore, the applications of radiomics for diagnosis, staging, assessment of tumor prognosis and treatment response according to different GI cancer types are explored. Finally, we discussed the existing challenges and limitations of radiomics in abdominal cancers and investigate future opportunities.

Median arcuate ligament syndrome (Dunbar syndrome).

Median arcuate ligament syndrome (MALS) is a rare condition which is due to the compression of celiac trunk by low riding of fibrous attachments of median arcuate ligament and diaphragmatic crura. Technically, MALS is a diagnosis of exclusion, consisting of vague symptoms comprising of postprandial epigastric pain, nausea, vomiting and unexplained weight loss. Different imaging modalities like Doppler ultrasound, computed tomography, magnetic resonance imaging and mesenteric angiogram are helpful to demonstrate celiac axis compression. The goal of treatment is decompression of celiac trunk either by open, laparoscopic or robotic method along with adjuvant interventional procedures like percutaneous transluminal angioplasty (PTA) and stenting. Surgical is the mainstay of treatment. This approach is based on open, laparoscopic or robotic release of compressed ligament along with celiac ganglionectomy and celiac artery revascularization. The role of interventional radiology is limited to angioplasty and stenting to open the stenosis rather than addressing the underlying compression of celiac trunk which has resulted in the symptoms. However, both the diagnosis and therapeutic intervention remains challenging. Extensive evaluation of etiology and pathophysiology of MALS and addressing the same through minimally invasive techniques may yield best prognosis in future. In this review article, we discuss briefly about the MALS in terms of etiology, diagnosis and its management including the role of interventional radiology.

Endoscopic Management of a Trauma-Induced Urethral Pseudoaneurysm.

Background: Urethrorrhagia is a rare urologic event with urethral pseudoaneurysm a potential cause. All previous reports of urethral pseudoaneurysm have been managed with angioembolization. Case Report: A 25-year-old man experienced delayed presentation of urethrorrhagia secondary to urethral pseudoaneurysm formation after significant pelvic trauma. Urethral pseudoaneurysm was definitively managed with endoscopic transurethral external compression. Endoscopic thrombosis of pseudoaneurysm was confirmed by postprocedure angiography. Conclusion: Endoscopic transurethral management of a urethral pseudoaneurysm is an alternative form of treatment for urethral pseudoaneurysm, with potentially fewer downstream effects on voiding and erectile function.

Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses.

PURPOSE: To determine success and complication rates of percutaneous transjejunal biliary access (PTJBA) in patients with bilioenteric anastomoses. MATERIALS AND METHODS: In a single-center, retrospective study, 169 PTJBA procedures were performed over a 13.8-y period in 60 subjects (47 male; mean age, 54.5 y). Indications for biliary interventions were cholangitis (137 cases, 45 subjects) or hyperbilirubinemia (32 cases, 18 subjects). All patients had antecolic bilioenteric anastomoses without surgical fixation to the peritoneum (liver transplantation with hepaticojejunostomy, n = 37; hepatectomy with hepaticojejunostomy, n = 8; hepaticojejunostomy only, n = 12; pancreaticoduodenectomy, n = 3). RESULTS: Initial PTJBA was successful in 140 cases (82.8%) in 35 subjects (58.3%). Twenty-one additional PTJBAs (12.4%) in 18 subjects (30.0%) were performed secondarily following a conventional transhepatic approach. Radiographic markers on the Roux-en-Y limb (P = .14, odds ratio [OR] = 2.98) or preprocedural imaging (P = .13, OR = 10.00) did not increase the odds of successful PTJBA. There were 7 major complications (4.3%) in 6 patients (10.0%) requiring hospitalization longer than 5 d, and 37 minor complications (23.0%) in 19 patients (31.7%). No procedure-related mortality was observed. Minor and major complication rates were not affected by time between bilioenteric anastomosis creation and PTJBA (P = .70, OR = 1.00; P = .62, OR = 1.00), longer dwell time of a transjejunal drain (P = .68, OR = 1.02; P = .49, OR = 0.71), or access size (P = .40, OR = 0.85; P = .23, OR = 0.59). CONCLUSIONS: PTJBA is a relatively safe technique with a high success rate in patients with bilioenteric loops that are not surgically fixed to the peritoneum.

Fine-Needle Aspiration of Epithelial-Myoepithelial Carcinoma of the Parotid Gland With Prominent Adenoid Cystic Carcinoma-Like Cribriform Features: Avoiding a Diagnostic Pitfall.

OBJECTIVES: Epithelial-myoepithelial carcinoma (EMC) is a rare salivary gland malignancy associated with an overall good prognosis. Fine-needle aspiration (FNA) typically shows a dual population of myoepithelial and ductal cells. Rarely, acellular matrix globules are present, raising a differential diagnosis of adenoid cystic carcinoma (AdCC), a more aggressive salivary gland malignancy associated with a poor long-term prognosis. We report an FNA case of EMC containing a predominant pattern of AdCC-like spherical globules. METHODS: We compare features of an unusual case of EMC with those of cribriform AdCC to arrive at morphologic clues to the correct diagnosis. RESULTS: Distinguishing features of EMC on FNA include (1) a prominent population of myoepithelial cells vs the predominance of basaloid cells in AdCC and (2) cohesive matrix globules with a peripheral rim of pale-staining basement membrane material compared with the dyscohesive matrix globules of AdCC. Immunochemical markers (S100, CD117, and MyB) are also useful. CONCLUSIONS: Although EMC and AdCC can both contain spherical matrix globules, close evaluation of the cytomorphology of the globules and their relationship to surrounding cells provides a clue to distinguish the two neoplasms.

Purposeful creation of a pneumothorax and chest tube placement to facilitate CT-guided coil localization of lung nodules before video-assisted thoracoscopic surgical wedge resection.

PURPOSE: To evaluate the feasibility and efficacy of pneumothorax creation and chest tube insertion before computed tomography (CT)-guided coil localization of small peripheral lung nodules for video-assisted thoracoscopic surgical (VATS) wedge resection. MATERIALS AND METHODS: From May 2011 to October 2013, 21 consecutive patients (seven men; mean age, 62 y; range, 42-76 y) scheduled for VATS wedge resection required CT-guided coil localization for small, likely nonpalpable peripheral lung lesions at a single institution. Outcomes were evaluated retrospectively for technical success and complications. RESULTS: There were 12 nodules and nine ground-glass opacities. Mean lesion distance from the pleural surface was 15 mm (range, 5-35 mm), and average size was 13 mm (range, 7-30 mm). A pneumothorax was successfully created in all patients with a Veress needle, and a chest tube was inserted. All target lesions were marked successfully, leaving one end of the coil within/beyond the lesion and the other end of the coil in the pleural space. The inserted chest tube was used to insufflate air to widen the pleural space during coil positioning and to aspirate any residual air before transfer of the patient to the operating room holding area. Intraparenchymal hemorrhages smaller than 7 cm in diameter developed in two patients during coil placement. All lesions were successfully resected with VATS. Histologic examinaiton revealed 13 primary adenocarcinomas, four metastases, and four benign lesions. CONCLUSIONS: Pneumothorax creation and chest tube placement before CT-guided coil localization of peripheral lung nodules for VATS wedge resection facilitates the deployment of the peripheral end of the coil in the pleural space and provides effective management of procedure-related pneumothorax until surgery.

Segmental arterial mediolysis.

Segmental arterial mediolysis (SAM) is an uncommon, nonatherosclerotic, noninflammatory, large- to medium-sized arteriopathy first described in 1976. It is characterized histologically by vacuolization and lysis of the outer arterial media leading to dissecting aneurysms and vessel rupture presenting clinically with self-limiting abdominal pain or catastrophic hemorrhages in the abdomen. Patients of all ages are affected with a greater incidence at the fifth and sixth decades. There is a slight male predominance. Imaging findings overlap with inflammatory vasculitis, collagen vascular disease, and fibromuscular dysplasia. The presence of segmental dissections involving the celiac, mesenteric, and/or renal arteries is the key distinguishing features of SAM. Inflammatory markers, genetic tests for collagen vascular disorders, and hypercoagulable studies are negative. Anti-inflammatory agents and immunosuppressants are not effective. A mortality rate of 50 % has been attributed to the acute presentation with aneurysmal rupture necessitating urgent surgical or endovascular treatments; in the absence of the acute presentation, SAM is a self-limiting disease and is treated conservatively. There are no established guidelines on medical therapy, although optimal control of blood pressure is considered the main cornerstone of medical therapy. The long-term prognosis is not known.

Intravascular ultrasound-guided inferior vena cava filter placement using a single-puncture technique in 99 patients.

PURPOSE: To assess the feasibility and safety of intravascular ultrasound (IVUS) to guide inferior vena cava (IVC) filter placement using a single venous puncture technique. MATERIALS AND METHODS: Medical records of all patients who had IVC filters placed under IVUS guidance between January 1, 2005 and December 31, 2011 were retrospectively reviewed for pertinent history, results, and complications. All filters were placed using a single venous puncture technique. RESULTS: Filters were successfully placed within the IVC in 94% of the patients with 6 malpositioned filters (4 in the iliac veins and 2 in the suprarenal IVC). Complications included groin hematoma (4%), deep venous thrombosis at the site of vascular access (2%), and filter tilt >15° along the long axis of the IVC (2%). CONCLUSIONS: The IVUS-guided IVC filter placement using a single venous puncture technique is technically feasible and safe when compared to case series using a double venous puncture technique.

Preliminary experience with Option inferior vena cava filter.

OBJECTIVES: To evaluate the safety and efficacy of Option inferior vena cava (IVC) filter during placement and short-term follow-up. METHODS: A total of 165 patients (mean age: 60-years) who received Option IVC filter from June 2009 to July 2011 were included. In all, 42 patients presented with deep vein thrombosis (DVT), 26 with pulmonary embolism (PE), and 17 with both. All outcomes were examined until April 30, 2012. RESULTS: The filters were successfully deployed in 161patients. During follow-up (mean, 9.5 ± 0.68months), 10 patients were diagnosed with post-filter PE and 13 patients with DVT. There were no instances of fatal PE. Follow-up abdominal computed tomography was available in 60 patients and demonstrated filter-related problems in 8 patients (2: penetration of filter legs, 5: asymptomatic nonocclusive thrombus, and 1: caval occlusion). There were no instances of filter migration or fracture. In total, 27 filters were successfully retrieved after a mean of 5.27 ± 0.76 months. CONCLUSION: The Option filter was effective and safe during implantation and short-term follow-up and associated with high technical success at retrieval.

Transarterial chemoembolization with Doxorubicin-eluting microspheres for inoperable hepatocellular carcinoma.

BACKGROUND: Therapy with drug-eluting microspheres was recently introduced with an aim to decrease the high postoperative morbidity associated with chemoembolization with lipiodol. The purpose of our study was to assess the safety and efficacy of chemoembolization with doxorubicin-eluting microspheres (DEB-TACE) for inoperable hepatocellular carcinoma (HCC). MATERIAL AND METHODS: In this IRB-approved retrospective study, 54 patients (44 men; median age, 61 years) with inoperable HCC were treated with DEB-TACE. HCC was diagnosed by biopsy in 43 and with a combination of α-fetoprotein (AFP) and imaging in 11. Patients with Child-Pugh A, B, C cirrhosis were 27, 25, 2, respectively. Twenty-one patients had received local therapies prior to DEB-TACE. Tumor was multifocal in 30. Eight patients had branch portal vein thrombosis. DEB-TACE was performed using 300-500µ LC Beads™ mixed with 100 mg of doxorubicin. Twenty-two patients had one DEB-TACE procedure, 23 patients had 2, 8 patients had 3, and 1 had four procedures. Response rate (RR) was assessed using AFP, RECIST, and EASL criteria on CT/MRI at 1 and 3 months. Overall median survival and survival rates at 6, 12, and 24 months were calculated. RESULTS: DEB-TACE was technically successful in all. Mean hospital stay after the procedure was 1.59 days. Thirty-day mortality was 0%. RR based on AFP was 26%. At 1 and 3 months, CR + PR were 14.8% and 35%, SD 74.1% and 50%, and PD 11.1% and 15%. Overall median survival was 445 days (95% CI 312-590). The survival rates at 6 months, 1 year, and 2 years were 77%, 59%, and 32% respectively. CONCLUSIONS: Chemoembolization with doxorubicin-eluting microspheres is safe and well tolerated in patients with inoperable HCC. Its efficacy is comparable to the historical controls. However, further prospective studies are required to confirm its efficacy.

Arterial interventions for renovascular hypertension.

Renovascular hypertension is a major cause of secondary hypertension. It affects relatively younger patients. The unifying pathology is renal artery stenosis. The most common cause is atherosclerosis accounting for about 90% of cases with fibromuscular dysplasia being the second most common cause. Both of these are amenable to percutaneous interventional therapy. With the advent of new medical therapies, the control of blood pressure has improved significantly. In well-selected patients, renal arterial intervention has a good outcome. The intervention includes renal angioplasty and stenting. In this article, the authors review the role of percutaneous intervention and the techniques involved with renal angioplasty and stenting for the treatment of renovascular hypertension.